Open Pilon Fracture Postoperative Outcomes with Definitive Surgical Management Options: A Systematic Review and Meta-analysis

Background: Pilon fractures represent one of the most surgically challenging fractures in orthopaedics. Differenttechniques exist for their management, with open reduction and internal fixation (ORIF) and External fixation (Ex-Fix) the most widely used. Whilst there is a plethora of data regarding these strategies for Pilon fractures as a whole,very limited data exists solely on the management of open Pilon fractures. This study aimed to elucidate how surgicalmanagement options can influence postoperative complications, and if this can influence future management protocols.Methods: We conducted a search in PubMed, EMBASE and CENTRAL for postoperative complications andfunctional outcomes in open pilon fractures in those treated with Ex-Fix vs ORIF (PROSPERO-CRD۴۲۰۲۰۱۸۴۲۱۳).The postoperative complications measured included non-union, mal-union, delayed union, bone grafting, amputation,osteoarthritis, deep infection and superficial infection. Functional outcomes in the form of the AOFAS score was alsomeasured where possible. We were able to carry out a meta-analysis for both deep infections and non-unions.Results: The search yielded ۳۰۹ results and a total of ۱۸ studies consisting of ۴۸۴ patients were included. All fracturesincluded were open, and consisted of ۶۴ Gustilo-Anderson Type I, ۱۴۸ Type II, ۱۰۳ Type IIIa, ۹۰ Type IIIb and ۹ TypeIIIc. ۶۰ Type III fractures could not be further separated and ۱۲ were ungraded. Both ORIF and Ex-Fix were found tohave statistically similar AOFAS scores (P=۰.۶۸۲). For all included studies, the Ex-Fix group had significantly higherrates of superficial infections (P=۰.۰۰۱), non-unions (P=۰.۰۰۱), osteoarthritis (P=۰.۰۰۱) and bone grafting (P=۰.۰۰۱).The meta-analysis found no significant difference in non-union (pooled OR=۰.۲۵, ۹۵% CI: ۰.۰۳ to ۲.۲۴, P=۰.۴۴) or deep infection rates (pooled OR=۱.۳۵, ۹۵% CI: ۰.۱۱ to ۱۶.۶۹, P=۰.۱۲) between the ORIF and Ex-fix groups.Conclusion: Based on our study, while Ex-Fix and ORIF have similar functional outcomes, Ex-Fix appears to havea significantly higher risk of postoperative complications which must be considered by surgeons when choosingsurgical management options. Further research, ideally in a randomised control trial format, is required to definitivelydemonstrate ORIF superiority in the management of open pilon fractures.Level of evidence: I